Provider Demographics
NPI:1558356741
Name:MEDALLIANCE MEDICAL HEALTH SERVICES INC
Entity Type:Organization
Organization Name:MEDALLIANCE MEDICAL HEALTH SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAHRIAR
Authorized Official - Middle Name:
Authorized Official - Last Name:DANESHVAR
Authorized Official - Suffix:
Authorized Official - Credentials:CASC
Authorized Official - Phone:718-933-1900
Mailing Address - Street 1:625 E FORDHAM RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5049
Mailing Address - Country:US
Mailing Address - Phone:718-933-1900
Mailing Address - Fax:718-563-4039
Practice Address - Street 1:625 E FORDHAM RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5049
Practice Address - Country:US
Practice Address - Phone:718-933-1900
Practice Address - Fax:718-563-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0261903261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02619203Medicaid
NYWEU411Medicare PIN
NY02619203Medicaid